THE two most serious health problems of this decade are the deadly duo: Obesity and Type 2 Diabetes Mellitus. The International Diabetes Federation (IDF) estimates (as of January 2010) that there are more than 430 million diabetic people worldwide, and that most of them are from the Asia Pacific region.

This pandemic is shifting eastward as more and more upwardly mobile Asians give up their traditional, healthy diet of rice, vegetables and fish protein for fashionably western diets made up primarily of calorie-laden, artery-clogging fast food.

In a July 2011 report, the U.S. Center for Disease Control pronounces one in three Americans as obese. All the American states have obesity rates exceeding 20 percent not one state met the national ‘Healthy People 2010’ goal to lower the prevalence of obesity to 15 percent by the end of the target year.

The ‘heaviest’ states are all in the mid-West: Alabama, Arkansas, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Oklahoma, South Carolina, Tennessee, Texas, and West Virginia. Mississippi has the unfortunate distinction of having the most obese population (34 percent); Colorado has the relatively leanest (21 percent).

The increase in the number of overweight and obese individuals parallels the rise in the number of persons with diabetes (PWD). Our sedentary lifestyles tip the energy balance toward weight gain. The world’s children are at the center of this explosive problem. Type 2 diabetes now occurs at progressively younger ages. And, ironically, because improved medical care has extended life expectancy, these children will have to live with the complications of diabetes far longer than their grandparents did, a generation ago.

We have not finished with the diabetes math just yet. The triple threat is a triad of the deadly duo plus hypertension. The deadly quartet is the triple threat plus dyslipidemia (low HDL-C, the good cholesterol; high LDL-C, the bad cholesterol; high triglycerides or fat). This is what physicians call the ‘metabolic syndrome’—the perplexing clustering of metabolic abnormalities with various other cardiovascular and life-habit risk factors—that are a major cause of disease. The more risk factors you have, the higher the likelihood you will die from a heart attack or stroke.

Sugar, sugar everywhere
How does diabetes come about?
Rice, bread, potatoes—any carbohydrate we eat—is in our stomachs broken down by digestive enzymes into glucose. This is sugar’s simplest form, the raw material that generates the body’s energy. Protein and fat are alternative glucose sources that are stored in muscle and fat tissue and mobilized when we are fasting.

Normally, after a meal, the sugar in our stomach triggers sensors that alert the pancreas, a small factory that lies behind the curve of the stomach. Special cells, the b-cells of the Islets of Langerhans, discharge stored insulin in two bursts—an immediate tall spike, followed by a second, smoother curve that releases insulin in a steady stream (but smaller amplitude) that brings down glucose levels to normal.

Insulin is a hormone, a chemical messenger that docks on insulin receptors on every cell in the body—especially in insulin-sensitive tissues: the liver, muscle and fat cells—and sets off a complicated chain reaction that allows specific transporters to pick up glucose waiting in the blood stream outside the cell doors. Once inside the cell, glucose undergoes a chemical cycle in the mitochondria, the cell’s powerhouse, which generates energy as adenosine triphosphate (ATP), so our hearts can pump, so we can breathe, think, see, and speak—live.

When insulin receptors are less responsive to the effect of insulin, the body is in a state of insulin resistance. Higher-than-normal amounts of insulin are necessary to maintain blood sugars at normal levels. In spite of the high levels of insulin, the insulin signal inside the cell is weak and fewer transporters travel to the cell wall to pick up the waiting glucose. Much less glucose enters the cell.

To compensate for insulin resistance, the pancreas must work overtime to produce extra insulin. Unfortunately, the pancreas cannot keep this up for long, and the compensatory mechanism invariably fails. Eventually, the b-cells are exhausted, insulin production drops and fasting blood glucose levels rise above 126 mg %—the diagnostic cut off for diabetes.

This deficiency in b-cell insulin production, together with a resistance to the effect of insulin in the body’s tissues, results in Type 2 diabetes mellitus.

The diabetic has sugar everywhere but his body cannot use it properly. In the midst of plenty, the body starves for glucose. The liver is the hub of glucose production. In recent years, our understanding of the diabetes develops has broadened to include the role of the a-cells of the pancreas, which produce the hormone, glucagon. Glucagon is the big-spender material girl of metabolism, driving catabolism rather than being anabolic, stimulating the liver to make more and more glucose, rapidly consuming its stores of glycogen during an overnight fast. Once the liver has run out, it uses substrates like fat and protein through alternate metabolic pathways whose end product is glucose. This production line is primarily responsible for the morning sugar surge upon awakening, measured as fasting blood sugars.

But all that extra sugar is useless and merely inflates the glucose levels further. It is a destructive cycle. Excess glucose is toxic to cells; it damages small and large arteries, oxidizes blood and lipids, leaks out in the urine, drawing water along with it causing frequent urination. Because the body wastes all its energy and cannot store any, the patient loses weight and has to eat voraciously to replenish himself.

Low levels of the hormones, glucagon like peptide 1, (GLP-1) and gastric inhibitory peptide (GIP), also result in high sugar levels in diabetes. Special cells in the lower gastrointestinal tract secrete these incretins, which augment the pancreatic secretion of insulin after a meal and help bring the glucose back to pre-meal levels within two hours of eating.

Dr. Ralph de Fronzo, a diabetes expert from the United States who visited Manila, uses the term “ominous octet,” to include the role of free fatty acids in the bloodstream that feed fat to the liver; the yet not clearly understood role of different brain neurotransmitters; and the kidney’s role in managing glucose transport into the urine. As researchers continue to investigate these areas, we expect a clearer understanding of how diabetes comes about. Who knows, in a few years, the octet may become the ‘Terrible Ten.’

National Vital Statistics
The most recent National Health Survey (2008) found the prevalence of high blood sugar among Filipinos to be 4.8 percent—an increase from the previous prevalence of 4 percent. Ninety percent of the population have blood sugar within the normal range. The percentage of Filipinos with impaired fasting glucose and impaired glucose tolerance—both pre-diabetic conditions—are three and seven percent respectively. This means that—based on the estimated population of 85 million in 2008—approximately 4.25 million Filipinos have diabetes. What is even more distressing is that nearly double that number—8.5 million of our people—have prediabetes, and don’t know it.

The same survey also showed 27 percent of Filipinos to be either overweight or obese—higher than in previous years.

Burn fat, drop kilos
Weight loss brings huge benefits. More than any lifestyle variable, the loss of even 5 to 10 percent of initial body weight improves the metabolic syndrome—may even reverse all its risk factors. It improves blood pressure and controls both lipid abnormalities and blood sugar.

Losing weight, however, is easy to say and hard to do. The body must burn more energy than it takes in as food. The key change is to increase servings of fruits, vegetables, and high-fiber whole grains, fish and low-fat dairy products that are nutrient-dense; and to take low-energy foods to displace the intake of low-nutrient, high-calorie foods.

The goal of dietary therapy is an energy deficit of 500-1000 kcal/d, leading to a weight loss of no more than 1-2 lb. /wk. This way you keep weight off slowly, but surely.

Everyone benefits from regular physical exercise. By itself, exercise produces much less weight loss than restricting calories alone. Moderate physical exercise—between 30-60 minutes a day—optimizes maximum oxygen uptake, increases basal energy expenditure and improves cardiovascular fitness. The US Surgeon General advocates brisk walking of 3 miles a day and resistance training three times a week.

For an exercise program to be sustainable the activity should be fun and something the patient enjoys, ideally incorporated into his daily activities.

A comprehensive physical activity prescription should include warm-up and cool-down periods, with exercises that help:

Improve cardiovascular fitness
Increase strength with resistance training Enhances flexibility through a wide range of motion.

The foundation of lifestyle modification is medical nutrition therapy (MNT); at least 150 minutes a week of regular aerobic exercise, regular checkups, medication and frequent checks that result in a 5-10 percent weight loss within 6 months.

Diabesity treatment updates
The early, appropriate and aggressive treatment of diabetes and obesity— “diabesity”— is essential to prevent the multiple complications and organ dysfunctions that affect the large and small blood vessels and lead to heart attacks, strokes, blindness, kidney failure, amputations and short lifespans. Diabesity also increases a person’s risk for some cancers.

Unfortunately, these disorders are as multifactorial as their treatment. There is no single pill or polypill that can take care of everything. New drugs in the sugar-lowering armory include the incretin mimetics (pharmacologic analogues that mimic the action of our own GLP-1) like exenatide (Byetta) or liragutide (Victoza) that are injectable options other than insulin. The side effects of these drugs include nausea, vomiting, early satiety and blunting of appetite through their action in the brain. Obese and overweight diabetics may benefit from the weight loss.

Incretin enhancers currently available in the Philippines include sitagliptin (Januvia), vildagliptin (Galvus) or saxagliptin (Onglyza), tablets that block the action of the enzyme that breaks down GLP-1. This allows our body’s own GLP-1 to continue working in our circulation for much longer than it normally would.

Sodium glucose co-transporter (SGLT) inhibitors (dapaglifozin) work at the level of the kidney pump system that regulates the spillage of sugar in the urine. When blood glucose levels are high, the concentration exceeds and overwhelms the kidney’s filtering capacity and the sugar exits from the proximal tubules of the kidney into the urine. The sugar drags water out as well, resulting in copious amounts of sweet urine that attracts ants. This drug is undergoing clinical trials but suffered a recent setback: the American FDA did not approve the drug for licensing in July 2011.

The pharmacologic options for obesity are extremely limited. The worldwide withdrawal of sibutramine, a serotonin reuptake inhibitor that causes an early feeling of fullness (Reductil, Meridia) in 2010 leaves only orlistat (Xenical) on the market as an anti-obesity drug. Taken three times a day, orlistat works at the intestines, binding lipase, the enzyme that breaks down dietary fat, resulting in less fat absorption and messy, oily spotting in stool.

Another obesity drug, rimonabant, an endocannabinoid receptor blocker, was also in clinical trials and fell out of favor with the FDA a few years ago because of a high incidence of psychiatric side effects including severe depression.

Knife as a cure?
Bariatric surgery not only helps obesity and weight reduction but also has the potential to “cure” diabetes. The IDF released new guidelines in March 2011 that advocate surgery for patients with type 2 diabetes whose body mass index (BMI) is 35 kg/m2 or higher or when it is between 30 and 35 kg/m2 (For Asians, reduce the BMI action points by 2.5 kg/m2) with co-morbidities.

Physicians should offer this option if the patient has other cardiovascular risk factors, including hypertension, hyperlipidemia, and a history of heart attacks when medicine and lifestyle changes are unable to improve glucose control.

Although the procedure costs between $20,000-30,000, it is beneficial over the long term by saving on treating complications. The IDF estimates the cost at $172,000 for a person diagnosed at age 50 years and $305,000 at age 30 years, with more than 60 percent of this amount spent in the first 10 years after diagnosis.

The question of which gastric surgery procedure—temporary lap banding of the stomach or extensive, permanent bypass surgery—has better long-term outcomes in treating obesity and diabetes will require many more studies, subjects and years to settle.

No quick solutions
The solution to diabetes and obesity is not simple. Therapeutic lifestyle changes: making the right choices from meal-to-meal and getting more physical are the foundation of the rest of the patient’s life. Though pharmacotherapy may be necessary at some point, medications are only adjuncts to lifestyle. It is not a quick fix; diabetes and obesity require a change in lifestyle to deal with the problem.

Heavy cross, sweet life
Diabetes and obesity co-exist in more than 50 percent of patients. It is almost a chicken and-egg quandary: obesity and diabetes are chronic illnesses, lifetime burdens, and heavy crosses to carry.

Once the PWD accepts the life-altering diagnosis and recognizes his responsibility, educates himself about the disease, follows nutrition and exercise recommendations, takes his medication regularly and sees his physician faithfully, he can achieve good control over his diabetes.

Though the diagnosis of diabetes is forever, there still can be a sweet happily-ever-after. And though desirable body weight may be an elusive goal, tolerance, understanding and a little encouragement goes a long way in helping the vertically challenged someday reach not for the sky, but for their toes.